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Posted: October 15th, 2020

Clinical Case Study

Nursing Assignment: I need help writing a research paper.

Part 5: Recommending an Evidence-Based Practice Change Create an 8- to 9-slide PowerPoint presentation in which you do the following: · Briefly describe your healthcare organization, including its culture and readiness for change. · Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.

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Nursing Assignment: I need help writing a research paper.
nursing
urgent
1. Read the information about the case study with the chart materials provided or gather the necessary information from one of your patients.

2.Review the patient assessment information. What other assessments might you do in addition to those provided? What findings would you anticipate with this patient? Develop a care plan (use the template provided) based on the highest priority problem (1 nursing diagnosis, 2 goals, 3 interventions for each goal, 2 rationales for each intervention and evaluation for each goal). Complete an in-depth analysis reflecting your ability to prepare a case study based on principles derived from pharmacology, pathophysiology, psychology, nutrition, and evidence-based nursing practice guidelines. Remember to include an introduction to the patient, pathophysiology, history, nursing assessment (given and any additional), and related treatments.

3.Include selected references for your case study paper/care plan and use APA format.

4. A specific grading rubric and template are attached. The care plan should also be completed.

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Case Study: Hypothermia

Case Study: Hypothermia

Student name

Professor Daniel Jackson

Adult Health III

The patient is a 82-year old white female who was brought in to the hospital by the EMS on 1/18/2020. By report, the patient has a history diagnosis of hypertension, and COPD; the patient was brought in due to a fall at home in her garage, found by a friend. Her friend contacted the police, and the patient was brought in to Froedtert South (Kenosha Medical Center).

The admitting vital sighs revealed her blood pressure to be 150/90 mmHg, Pulse 45, oxygen saturation 95%, and temperature of 90.1 degrees F. The patient was not oriented, unable to recall incident due to loss of consciousness. Upon body assessment, the patient was noted with multiple bruises and swelling on the left arms and a bruise on the right ankle. Also redness was noted on the sacrum area.

Mayo Clinic describes hypothermia as a medical emergency that occurs when the body loses heat faster than it can produce heat causing a dangerously low body temperature. The desirable body temperature is 98.6; when the body falls below 95 F is consider hypothermia.

Most common manifestations of hypothermia include shivering, slurred speech or mumbling, slow, shallow breathing, weak pulse, lack of coordination, drowsiness or deficient energy, confusion or memory loss, loss of consciousness, and bright red, cold skin (Mayo Clinic, 2018). According to the Mayo Clinic, there are specific conditions that lead to hypothermia: Staying out in the cold too long, or being unable to get out of wet clothes or move to a warm, dry location.

As Dr. William H. Blahd, Jr and Dr. Adam Husney, discuss in the website Michigan Medicine University of Michigan medical treatment for hypothermia depends on the severity of the hypothermia for example treatment of mild hypothermia includes getting out of the cold or wet environment, using warm blankets, heaters, and hot water bottles. If someone suffers from moderate to severe hypothermia, the treatment has to be done at a hospital setting, where doctors can use special techniques to warm the core body temperature.

The patient has a history of COPD, anemia, hypertension and back and neck. She was treated for hypothermia, productive cough, and failure to thrive. The patient does not have a history of any surgeries. The patient is currently taking the following prescribed medication: Metoprolol, Losartan, Tramadol as needed for pain, Oxygen 2L as required, Hydrolazine 10 mg IV push and a continuous Normal Saline IV. Patient is currently NPO, with NG tube on. Standing orders to hold beta-blocker if heart rate is below 60.

The patient was admitted to Froedtert South (Kenosha Medical Center) with a diagnosis of hypothermia; the primary goal was to raise the body temperature to the normal range. Wet clothes were removed from the patient’s body and replace with a dry hospital gown; Oxygen 2L provided for comfort, an IV line initiated to replenish her body fluids with normal saline. A urine catheter was initiated to remove any remaining urine in the bladder and also to check her temperature. Cardiac monitoring initiated.

During the assessment, the patient was oriented x 2. Resident remained most of the time in bed with eyes close responsive upon calling her name. Pupil equal round reactive to light, and accommodates intact. The patient does not require hearing aids. Handgrips equal strength weak, and also foot pushes strength is equal. Smell intact and eye movement intact. On a scale of 0 to 10, patient report three pains at the moment. Mucous membrane noted to be dry, radial and pedal pulses present. Carotid pulses are palpable. Capillary refill <3 seconds. No jugular vein noted. Edema note on lower and upper extremities. The IV site on right forearm was patent. Patient has clear lung sounds, currently having a cough. No shortness of breath noted during the assessment. When reviewing the chart, no allergies were listed. VS: BP: 146/90 mmHg, Pulse 70, Temperature of 98.4 degrees F, room air O2 SAT 95%. Blood test conducted with the following result: carbon dioxide 23, chloride 115, creatinine 1.32, glucose 95, HCT 30.7%, Hgb 9.9, Wbc 7.6, platelets 165, potassium 3.4, sodium 144, BUN 19, calcium 7.5, BUN/CREATININE

14.4. The doctor order the following diagnostic test: Chest -X-ray due to productive cough that was negative for pneumonia. CT scans of the brain, no internal hemorrhage.

The patient has not been able to get off the tube feeding, and continuous to be NPO. The patient still has a nursing diagnosis of failure to thrive. According to the primary nurse, there has been a referral put in place for Hospice evaluation and treatment, the consent form pending to be sight by POA.

References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care. (10th ed.). Maryland Heights, MO: Mosby Elsevier.

Blahd, W. H., Jr, & Husney, A. (2018, September 22). Hypothermia and Cold Temperature Exposure. Retrieved March 8, 2020, from Michigan Medicine University of Michigan website: https://www.uofmhealth.org/health-library/ aa53968spec

Mayo Foundation for Medical Education and Research. (2018, January 6). Hypothermia. Retrieved March 8, 2020, from the Mayo Clinic website: https://www.mayoclinic.org/diseases-conditions/hypothermia/symptoms-causes/ sync-20352682

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